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ORIGINAL RESEARCH PAPER Volume-6 | Issue-10 | October-2017 | ISSN No 2277 - 8179 | IF : 4.176 | IC Value : 78.

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INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH

EVALUATION OF OUTPATIENT DEPARTMENT IN A PUBLIC SUPER SPECIALITY


HOSPITAL IN INDIA

Medicine
Dr Madhav
Madhusudan
Singh
Dr Pradeep
Srivastava
ABSTRACT
It has become essential for healthcare providers to understand and measure structure, process and outcome of OPD service and its gaps, so that any
perceived gap in delivery of service is identied and suitably addressed. A study was conducted at a super speciality public hospital to ascertain any
service gap between structure, process and outcome in respect of the hospital outpatient department (OPD) services.
Method : The study were conducted at Public Super speciality hospital by designing a checklist study on structure , process and outcome in OPD of
the hospital, using the IPHS Standards as the survey instrument. The checklist has been empirically evaluated in the hospital environment and has
been shown as a reliable and valid instrument in that setting. The checklist was designed to measure OPD Services about service provided using 118
Service elements, using a qualitative , structured checklist by direct observation by researcher .
The study concludes that signicant gaps in structure, process and outcome existed in the delivery of the hospital OPD services, which need to be
addressed by focused improvement efforts by the hospital management.

KEYWORDS
Hospitals, Outpatients, Evaluation , Structure , Process , Outcome

Introduction b Emergency Exit is provided. Yes


Health scenario is changing at a faster pace all over the world. Patient c Landscaping is done. No
satisfaction is one of the established yardsticks to measure the success
d The facility is well fenced to guard against Yes
of the services being provided in the hospitals. Hospital and healthcare
entry of animals.
services are vital components of any well-ordered and humane society,
e Adequate circulatory space for movement of Yes
and will indisputably be the recipients of societal resources. Out
trafc including trolley and wheel chairs is
Patient Department (OPD) Services is one of the important aspects of
present.
Hospital Administration. It means that, the patient is treated without
admitting him in the hospital and he goes home after treatment is done. f Adequate ramps are present to cater to the Yes
OPD services can also be called as Ambulatory Care Services. It is the requirements of immobile/disabled patients.
looking glass of the hospital and reects its functioning being the rst g Accommodation (Semi-Full furnished) No
contact between the patient and the hospital staff. It is very difcult to facilities (as per grades) for the core staff i.e.
quantify the satisfaction and gauze receptiveness of health systems as MO, Nurse, and Pharmacist is available.
not only the clinical but also the non-clinical outcomes of care h Housekeeping and Security are present/out Yes
inuence the patient satisfaction1. Discrepancy between patient belief sourced as per a MOU with the provider on
and the services received is most often the source of decreased certain quality criteria.
satisfaction. However, the primary role of the hospital is patient care j There is 24X7 availability of electricity and No
and quality of care. potable water supply with identied alternate
sources.
The study were conducted at a Public Super speciality hospital in k Arrangement for re safety is present. Yes but all
outpatient department to ascertain any perceived service gap between re points not
structure , process and outcome about quality of the outpatient functional
department (OPD) services being offered by hospital. l Attendants' lounge (temporary stay facility) is No
provided within the campus.
Materials and Method m Adequate drainage system is inbuilt Yes
The study were conducted at Public Super speciality hospital by
designing a checklist study on structure , process and outcome in OPD 2. FUNCTIONAL PLAN OF THE OPD
of the hospital, using the IPHS Standards as the survey instrument. The a. The OPD building has good functional plan Yes
checklist has been empirically evaluated in the hospital environment having ear marked space for waiting area,
and has been shown as a reliable and valid instrument in that setting. Minor OT, Sterilization Room, Pharmacy,
Dressing Room, Injection Room, X-ray Room,
The checklist was designed to measure OPD Services about service Dark Room, Patients Wards, Store Room (for
provided using 118 Service elements, using a qualitative, structured drugs, linen and equipments), Counselling
checklist by direct observation by researcher. Centres, Administrative Ofce, Toilet (male &
female) with running water facilities, Nurses
Research Design: Exploratory & Descriptive study by checklist Room, Immunization, Laboratory services
should be as per Hospital policy like Blood
Result: collection room.
The evaluation outcome is as follows: b. Facility has treatment room furnished and Yes
equipped with hydraulic cardiac bed, pulse (Except
PHYSICAL FACILITIES Oximeter, ECG and Central oxygen line. hydraulic
cardiac bed)
1. PHYSICAL FACILITIES in OPD
c. There is a dedicated room for visiting doctors No
a Main entrance is easily identiable, welcoming Yes in OPD.
and well lit.
International Journal of Scientic Research 47
Volume-6 | Issue-10 | October-2017 ISSN No 2277 - 8179 | IF : 4.176 | IC Value : 78.46

3. EQUIPMENTS & INSTRUMENTS b Is there a transport facility from main road to the Yes
a The facility has adequate number of Yes facility, in case it is at signicant distance?
equipments along with instruments as stated in c Adequate sign postings are available at various strategic Yes
ME Scale of CH. locations so as to guide the patients to the facility.
b The equipments are in functional order and No (Roughly 9. AVAILABILITY OF STAFF
have an up time of 98%. 40% a At least 01 medical ofcer and 01 nurse are available at Yes
Equipments all times in the facility.
found non-
b Facility is guarded by Security personnel 24X7. Yes
functional )
c Available staff are immunized and insured for health/ Yes
c There is appropriate mechanism for repair, Yes hospitalization.
maintenance and two year renewable AMC of
all the equipments. 10. EVALUATION OF PATIENT 6
d The instruments used are adequately Yes a All patients undergo assessment with privacy and Yes
disinfected, sterilized and kept in good working dignity.
condition. b The nurse carries out assessment in terms of noting the Yes
e Utilization of equipments is monitored on No vitals, height and weight of the patient in a pre-
regular basis. designated area of the OPD.
f Organization has resources for ensuring skill No c Medical ofcer documents the ndings of the patient in Yes
based training on use/ handling of equipments. a denite area in the OPD.
4. MANPOWER & STAFFING d Advice for medication and investigation is documented Yes
a The stafng norms as stated in govt scale for Yes in predened areas of the card.
hospital are maintained. e. The documentation is legible, timed, dated, named and Yes
b Roster for doctor and nurses is displayed. No signed by the medical ofcers.
c Disaster Management drill SOP Avlb Yes f The instruction is communicated to the patient in an Yes
understandable (verbal and written) manner.
5. DRUGS
g A record of all such assessments is maintained (for time Yes
a Availability of drugs and surgical consumable No ( Only 60
limits as per regulations) in the facility.
are ensured. % of total
inventory 11. CARE OF PATIENTS
available ) a The staff is courteous, humane and empathetic. Yes
b Availability of drugs is displayed along with No b Care is commensurate with the amenities available. Yes
expiry dates. c Care is provided in manner in which dignity and privacy Yes
c Medical Ofcers prescribe drugs based on the No of patient is maintained.
available formulary or essential drug list. d Organization has Care, Admission, Referral and Yes
Discharge Policies.
e Organization has written SOPs on Care. No
d Medicines dispensed have clear instruction on Yes
dose and schedule for consumption purposes. f Organization has written Consent Policy. Yes
6. TRANSPORT & AMBULANCE g Care is comprehensive in nature i.e. preventive, Yes
a There is at least one ambulance. Yes promotive, curative and rehabilitative in nature.
b Driver for the same is available at all times. Yes h Documentation for all procedures carried out in the Yes
c Ambulance is in working condition at all times. Yes facility is mentioned in the case records.
d Emergency drugs available in the ambulance. NO (In A&D j All the instruction by the medical ofcer is legible, Yes
Dept) dated, timed, named and signed.
e Basic resuscitation kit available in the NO (In A&D k Patient's condition is communicated to the family Yes
ambulance. Dept) members.
f The Stretcher trolleys and wheel chairs are in Yes l In case of death, a death summary is given to the No
working condition all the times. patient's family.
7. COMMUNICATION FACILITIES m An informed consent is obtained for patients undergoing Yes
any procedures.
a The centre has adequate stationary for written Yes
communication. n A list of procedures for which informed consent to be No
obtained is available in the facility.
b At least 2 telephone connections are available Yes
in the facility at all times. o The consent forms are in vernacular/local language. No
c Arrangements for a public address system Yes (Only
available. in
English
d Organization uses Signboards, Posters or/ and Yes )
wall painting displaying the activities and
services (along with timings) at the facility and p Consent is obtained either by the medical ofcer or the Yes
the important contact numbers at prominent nurse.
sites in the campus. These are in local 12. CONTROL OF INFECTION
language. a Infection Control Policy is available. Yes
e Campaigns for National Health Programs are Yes b Identied/ ear marked resources (0.5% Sodium No
displayed in the form of wall painting or Hypochlorite etc.) for infection control are available.
boards.
c Written protocols on cleaning of the infection prone Yes
f Lay out map of the facility and signage is in Yes areas and equipments used in patient care are available.
vernacular and symbols to address the needs of
vulnerable patients. d The facility takes all precautions to control infection. No
e Adherence to standard precautions is maintained by all No
Process assessment staff.
8. ACCESS TO FACILITY f Mopping (by latest available disinfectants) of all areas No
a The facility is easily assessable by approachable all Yes of the facility is carried out at least twice a day.
weather roads.

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Volume-6 | Issue-10 | October-2017 ISSN No 2277 - 8179 | IF : 4.176 | IC Value : 78.46

g Availability of running tap water for hand washing of Yes c Training for behavioural change communication is Yes
staff is maintained 24 hours a day. carried out and documented.
h The hospital environment is kept clean from litters, pest No d Training on all aspects of various national health Yes
and stray animals. programs is carried out.
j Adequate lighting arrangement and cross ventilation Yes e Evaluation of all such training is documented. No
present in all areas. f Several cash and non-cash incentives are given so as to Yes
k Sanitation of the toilets and hygiene of the staff is Yes constantly motivate the staff.
maintained. g Training is provided on both theoretical as well as Yes
l Adequate amount of disinfectants is available for Yes practical aspects.
disinfection purposes. h There are policy on encouragement and appreciation of Yes
m The facility is washed with soap and water regularly and Washed performers through incentives and awards.
a documentation there of is maintained. but no 17. LICENSES & STATUTES
records a All licenses e.g. Narcotics, Waste management, BARC, No
availabl AERB, re safety etc. as applicable are available in the
e hospital.
13. HOSPITAL WASTE MANAGEMENT
b Statutory requirements concerning patient and staff Yes
a Hospital waste generated is managed in accordance with No yet safety and welfare are met.
the Biomedical waste management and handling rules to
2016 implem OUTCOME STANDARDS
ent 18. Utilization Indices of the Centre
b General waste is collected in black bags. Yes a Recording of all parameters as stated in the monitoring Yes, but
c The sharps are subjected to deep burial and a pit for the Yes section of the Hospital is maintained. centrally
same is available with in the hospital premises b Data of utilization of OPD, Referral services (to & from Yes, but
according to the dimensions specied by the BMW the facility), ambulance services, MLC cases are centrally
rules 2016. analysed and maintained for continuous quality
d Facilities for syringe and needle destruction are Yes improvement
available and practiced. c Documentation & reporting of hospital statistics Yes, but
e Chemical treatment of plastics is carried out by using Yes centrally
freshly prepared bleaching lotion. 19. Statistics
f A site for composting of biodegradable waste is No a Statistics in terms of OPD attendance, is documented Yes
available with in the hospital premises. and reported
g Annual report is submitted to the competent authority Yes b Statistics for OPD published every quarterly Yes, but
by 31st January every year. monthly
h Accidental spillage of waste is reported and handled as Yes 20. Patient & Employee Satisfaction Survey1,2,3
per the BMW Guidelines. a On-going mechanism of conducting employee No
j Segregation of wastes is done in maximum of 3 bags Yes satisfaction survey is present.
(Black, Yellow & Blue). b Grievance Redress Policy and mechanism are in place. Yes
k Organization has resources to train all health personnel Yes c Organization has in use feedback mechanism like use of Yes
on handling BMW as per regulations. feedback forms, suggestion forms to be dropped in
suggestion/ complaint boxes at identied places.
14. RIGHTS & RESPONSIBILITIES OF PATIENTS
21. Health Information System
a Rights and responsibility of the patients are in Yes a Reporting of all the details is done through a web based Yes
accordance with Hospital Policy health information system to the army authorities on a
b A mechanism for grievance redressal is in place and No daily, weekly, monthly and annual basis.
practiced. b Health Information System tools are available Yes
c All redressal mechanisms are documented. Yes
d The patients have the right to their privacy, information Yes During the survey following observation were found which
and disease condition that shall not be disclosed to require urgent attention :
others. Landscaping was not done in OPD Area.
e Citizen charter and rights of the patients are displayed in No Accommodation (Semi-Full furnished) facilities (as per grades)
local language and are universal for the state. for the core staff i.e. MO, Nurse, and Pharmacist was not available.
There was 24X7 availability of electricity and potable water
15. RIGHTS & RESPONSIBILITIES OF STAFF
supply with identied alternate sources. There was no alternative
a The healthcare providers respect the patient's rights. Yes sources.
b Staff can demonstrate reasonable skill to provide care to Yes Attendants' lounge (temporary stay facility) were not provided
the patients. within the campus.
c Staff is entitled to all the benets (immunization, Yes The 60 % equipments were in functional order and have an up time
healthcare cover through insurance, semi to fully of 98%.
furnished staff quarters as per entitlement and Utilization of equipments were not monitored on regular basis.
availability, its maintenance and security) due to them Organization has resources for ensuring skill based training on
by virtue of their employment. use/ handling of equipments. But not utilized .
Roster for doctor and nurses were not displayed.
d Healthcare providers are immunized for Hepatitis, Yes Availability of drugs and surgical consumable were not ensured.
Tetanus etc. Only 60 % of total inventory available .
16. TRAINING, DEVELOPMENT & MOTIVATION OF Availability of drugs not displayed along with expiry dates.
STAFF Medical Ofcers were not prescribing drugs based on the available
a The organization arranges for continuous update of Yes formulary or essential drug list.
knowledge and skills of the staff. Emergency drugs were not available in the ambulance.
Basic resuscitation kit were available in the all ambulance.
b Periodic training programs on the subjects of waste Yes Organization don't have written SOPs on Care.
management, infection control, communication etc. are In case of death, a death summary were not given to the patient's
carried out and documented. family.

International Journal of Scientic Research 49


Volume-6 | Issue-10 | October-2017 ISSN No 2277 - 8179 | IF : 4.176 | IC Value : 78.46

A list of procedures for which informed consent to be obtained Suggestions:


were not available in the facility. The following is suggested:
The consent forms were not in vernacular/local language , it is 1. The existing Standing operative procedures need to be strictly
Only in English. adhered to, displayed in OPD and effectively monitored for
Identied/ ear marked resources (0.5% Sodium Hypochlorite etc.) evaluation of performance and improvements in the standards of
for infection control were not available. OPD services.
The facility doesn't takes all precautions to control infection. 2. Though most of the functioning in the OPD services area of the
Adherence to standard precautions were not maintained by all hospital is as per the SOPs but healthcare givers are grossly
staff. unaware of the availability of SOPs besides being ignorant about
Mopping (by latest available disinfectants) of all areas of the the existing procedures in their facility.
facility were not carried out at least twice a day. 3. Requirement of an Training on Soft Skills. Doctor patient
The hospital environment were not kept clean from litters, pest relationship and soft skills highly augment the delivery of high
and stray animals. quality of care to patients in all health care settings. It mainly
A site for composting of biodegradable waste were not available depends upon factors like behaviour of doctors and paramedics,
with in the hospital premises. clinical services provided to patients and physical comforts in the
A mechanism for grievance redressal was not in place and facility.
practiced. 4. Systematic studies is required on aspects of participation of
Citizen charter and rights of the patients were not displayed in healthcare provider will not only give new insight into patient
local language and are universal for the state. satisfaction but will also make the clientele aware of the
Evaluation of all such training development & motivation of staff signicance of healthcare provider and reduce the possibilities of
were not documented. unwarranted litigations and for that, active participation of
All licenses e.g. Narcotics, Waste management, BARC, AERB, healthcare providers is imperative4.
re safety etc. as applicable were not available in the hospital.
On-going mechanism of conducting employee satisfaction survey Conclusion
were not present. It was not conducted in last 5 yrs. Patients attending each hospital are responsible for spreading the good
image of the hospital and therefore satisfaction of patients attending
Discussion the hospital is equally important for hospital management. The
Understanding service provided in OPD is emerging as a critical issue hospital holds a very high reputation as a super speciality tertiary care
in health service delivery with recent research showing that Govt centre. Most of the patients are content with the services delivered in
hospitals do not have good OPD facilities as compared to Pvt Hospital. the OPD of the hospital. Some patients were not satised with the level
of care provided by the nursing staff in the hospital. Few gaps were
All the physical facilities in OPD is adequate, although building are old identied, if addressed, may help in improving the efciency and
and wide spread but OPD is functioning in optimal condition. Regular image of the hospital and garner more patient satisfaction. The study
maintenance is required. The OPD building has good functional plan had signicant implications for the hospital management, as OPD
having ear marked space for all dept. Most of the equipment were Service gaps along with their specic dimensions were correctly
found functional. 40 % equipment were under repair. The staffs are not identied, thus directing focused improvement efforts for addressing
posted as per stafng norms. All patients undergo assessment with such gaps in the hospital OPD services.
privacy and dignity and hospital is not following all treatment
protocol. Hospital waste generated is managed in accordance with the Conicts of interest
Biomedical waste management and andling rules 2016, but latest bag None identied
and collection bin are to be procured. Statistics in terms of OPD
attendance, is documented and reported. Statistics for OPD published References
every quarterly. 1. John E, Ware Jr, Mary K, Synder W, Wright Rusell, Davies Allyson R. Dening and
Measuring Patient Satisfaction with Medical Care. Journal Evaluation and Program
Planning. 1983; 3:24763.
Hospital is having large number of Welfare related facilities available 2. Tallavi Srinivas, Prasad G. Patient Satisfaction-A Comparative Study. Journal of the
which have positive impact on patient welfare as good practices as : Academy of Hospital Administration. 2003; 15(2).
3. March S, Stewart E, Robra B. Patient Satisfaction with Outpatient. 2006; 68(6):37682.
May I help you counter and personnel 4. Nelson A-M, Wood Steven D, Brown Stephen W. Improving Patient Satisfaction. Edit
Out of turn line for Old age patient / Disable patient par Jones and Bartlett Publishers. 1997.
Value added service like 5. Lam SSK. SERVQUAL: A tool for measuring patients opinion of hospital services
quality in Hong Kong. Total Quality Management 1997;8: 145152.
o Coffee shop / fruit stall 6. Hall JA, Roter DL, and Katz NR. Meta-analysis of correlates of provider behaviour in
o Cafeteria medical encounters. Medical Care, 1988; 26: 657-675.
o Golf cart / patient cart for patient movement
o Stn Patient Bus for patient
o Ambulance on call for stn emergency patient
o SMS alert on health related issues.
o Token system in OPD Pharmacy

The hospital is facing following Challenges in OPD :


The hospital had structural gaps i.e. building is old & requires
attention.
Patient load is more than expected .
During raining season the patient waiting area become
overcrowded .
There is no separate waiting area for Old patients .
The addl may I help people should be deployed in OPD area during
pick hr.
Lack of adequate IT trained personal and counter at registration
counter .
OPD is not fully automated .
Clinical pathways are not followed as per std protocol .

The study revealed that, most of the standard operating procedure are
not followed on ground. Though the documentation part was up to the
mark but the area of concern lies with awareness and implementation
of policies and procedures among the healthcare providers. The
hospital had structural gaps i.e. building is old & requires attention.
The utilization rate of various departments of OPD was adequate. Most
of the patients were found just satised with the services received5.

50 International Journal of Scientic Research